warehouseman pa rou 093 201104
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
WAREHOUSEMAN LIABILITY INSURANCE COMPLETE A SEPARATE PROPOSAL FOR EACH LOCATION 1.
Name of Applicant (Partners or Officers, if applicable)
2.
Mailing Address
3.
Location to be insured
4.
How long has current management operated this business?
5.
Description of Premises:
6.
a.
What is ground floor area?
b.
Height in stories?
c.
Total area (or cubic capacity) of premises available for storage?
d.
Identify and describe area(s), if any, occupied by tenant(s) or lessees
e.
Any basement(s)?
f.
Construction of walls?
Roof?
g.
Year built?
If recently remodeled, when?
If answer is “Yes”, is basement protected by automatic sump pump?
Protection of Premises a.
Is location sprinklered?
If “Yes”;
(1)
Wet or dry system?
If wet system, is storage area heated?
(2)
Manufacturers name and year installed
(3)
How often serviced?
(4)
Is system equipped with a Sprinkler Alarm?
By whom?
Describe b.
List any other private fire protection
c.
Public Protection at risk (ISO Grading)
d.
(1) Are your premises protected by an operating Premises Burglar Alarm System? Central Station?
Local Alarm?
(2) Extent of Protection (1-2-2 ½-3)?
Name of Protective Company
(3) Underwriters’ Laboratories Certificate No.? Date of Expiration
SAVE rou093-201104
Page 1 of 4
Royal Oak Underwriters, Inc.
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
e.
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
(1) State number of watchmen employed exclusively by you and maintained on duty within your premises all times when not regularly open to business (2) Do they signal to a Central Station and how often? (3) How many clock stations on premises? (4) How many pull boxes for Central Stations Signal?
7.
Are there any cold storage facilities?
8.
Estimated values in storage during previous year: Maximum
9.
Average
If so, complete Cold Storage section. Limit Requested
Deductible
Give percentage (by weight) of goods or commodities stored (dry storage): a.
Canned Foods
b.
Other Foodstuffs
c.
Furniture
d.
Industrial Chemicals
e.
Cloth products
f.
Paper products
g.
Home appliances (other than radio or TV equipment)
h.
Radio/Television/Electronic Equipment
i.
Liquor, wines, spirits
j.
Tobacco products
k.
Tires
l.
Explosives
m.
Other (describe)
10.
Total number of employees?
11.
List annual gross receipts for each of last five years (excluding any cold storage operations): a.
If any employee(s) bonded, give details
19_____ $ _____________ storage
d.
$ _____________ handling b.
$ _____________ handling
19_____ $ _____________ storage
e.
$ _____________ handling c.
19_____ $ _____________ storage 19_____ $ _____________ storage $ _____________ handling
19_____ $ _____________ storage $ _____________ handling
12.
What are estimated gross receipts (excluding cold storage operations) for the next twelve months? Storage
Handling
SAVE rou093-201104
Page 2 of 4
Royal Oak Underwriters, Inc.
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
13.
Give details of all previous losses, insured or not insured, occurring during past five years, which would have been recoverable under this type of insurance
14.
Name trade associations in which memberships have been held for one year or more
15.
Do you subscribe to a loss control program furnished by an outside organization? If “yes”, give name of organization and briefly describe services performed
16.
Attach a complete copy of the warehouse receipt(s) used
List any commodities stored
under special agreements and pertinent details of such agreements The applicant agrees that the statements contained in this proposal are true and that, if insurance is effected, any material misrepresentation or concealment of any information voids this insurance. COLD STORAGE SECTION If cold storage, please answer the following: 17. Type of refrigerant used? 18. Number of compressors? 19. Age of compressors? 20. When were compressors last serviced?
By whom?
21. Is maintenance program in force for the compressors? 22. Are thermostat checks made to determine temperature of facility?
If “yes”, how often If “yes”, how often
SAVE rou093-201104
Page 3 of 4
Royal Oak Underwriters, Inc.
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
23. Is high temperature alarm present?
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
If “yes”, is alarm local or central station?
24. Policy Term: From
To:
Signed:
Date:
By: To be completed by agent: Customers Goods Rates: Contents a.
Group 1
b.
Group 2
Agency Address
Reset Form rou093-201104
Submit by E-mail Page 4 of 4
Print Form
SAVE
Royal Oak Underwriters, Inc.
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
WAREHOUSEMAN LIABILITY INSURANCE COMPLETE A SEPARATE PROPOSAL FOR EACH LOCATION 1.
Name of Applicant (Partners or Officers, if applicable)
2.
Mailing Address
3.
Location to be insured
4.
How long has current management operated this business?
5.
Description of Premises:
6.
a.
What is ground floor area?
b.
Height in stories?
c.
Total area (or cubic capacity) of premises available for storage?
d.
Identify and describe area(s), if any, occupied by tenant(s) or lessees
e.
Any basement(s)?
f.
Construction of walls?
Roof?
g.
Year built?
If recently remodeled, when?
If answer is “Yes”, is basement protected by automatic sump pump?
Protection of Premises a.
Is location sprinklered?
If “Yes”;
(1)
Wet or dry system?
If wet system, is storage area heated?
(2)
Manufacturers name and year installed
(3)
How often serviced?
(4)
Is system equipped with a Sprinkler Alarm?
By whom?
Describe b.
List any other private fire protection
c.
Public Protection at risk (ISO Grading)
d.
(1) Are your premises protected by an operating Premises Burglar Alarm System? Central Station?
Local Alarm?
(2) Extent of Protection (1-2-2 ½-3)?
Name of Protective Company
(3) Underwriters’ Laboratories Certificate No.? Date of Expiration
SAVE rou093-201104
Page 1 of 4
Royal Oak Underwriters, Inc.
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
e.
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
(1) State number of watchmen employed exclusively by you and maintained on duty within your premises all times when not regularly open to business (2) Do they signal to a Central Station and how often? (3) How many clock stations on premises? (4) How many pull boxes for Central Stations Signal?
7.
Are there any cold storage facilities?
8.
Estimated values in storage during previous year: Maximum
9.
Average
If so, complete Cold Storage section. Limit Requested
Deductible
Give percentage (by weight) of goods or commodities stored (dry storage): a.
Canned Foods
b.
Other Foodstuffs
c.
Furniture
d.
Industrial Chemicals
e.
Cloth products
f.
Paper products
g.
Home appliances (other than radio or TV equipment)
h.
Radio/Television/Electronic Equipment
i.
Liquor, wines, spirits
j.
Tobacco products
k.
Tires
l.
Explosives
m.
Other (describe)
10.
Total number of employees?
11.
List annual gross receipts for each of last five years (excluding any cold storage operations): a.
If any employee(s) bonded, give details
19_____ $ _____________ storage
d.
$ _____________ handling b.
$ _____________ handling
19_____ $ _____________ storage
e.
$ _____________ handling c.
19_____ $ _____________ storage 19_____ $ _____________ storage $ _____________ handling
19_____ $ _____________ storage $ _____________ handling
12.
What are estimated gross receipts (excluding cold storage operations) for the next twelve months? Storage
Handling
SAVE rou093-201104
Page 2 of 4
Royal Oak Underwriters, Inc.
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
13.
Give details of all previous losses, insured or not insured, occurring during past five years, which would have been recoverable under this type of insurance
14.
Name trade associations in which memberships have been held for one year or more
15.
Do you subscribe to a loss control program furnished by an outside organization? If “yes”, give name of organization and briefly describe services performed
16.
Attach a complete copy of the warehouse receipt(s) used
List any commodities stored
under special agreements and pertinent details of such agreements The applicant agrees that the statements contained in this proposal are true and that, if insurance is effected, any material misrepresentation or concealment of any information voids this insurance. COLD STORAGE SECTION If cold storage, please answer the following: 17. Type of refrigerant used? 18. Number of compressors? 19. Age of compressors? 20. When were compressors last serviced?
By whom?
21. Is maintenance program in force for the compressors? 22. Are thermostat checks made to determine temperature of facility?
If “yes”, how often If “yes”, how often
SAVE rou093-201104
Page 3 of 4
Royal Oak Underwriters, Inc.
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
23. Is high temperature alarm present?
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
If “yes”, is alarm local or central station?
24. Policy Term: From
To:
Signed:
Date:
By: To be completed by agent: Customers Goods Rates: Contents a.
Group 1
b.
Group 2
Agency Address
Reset Form rou093-201104
Submit by E-mail Page 4 of 4
Print Form
SAVE
Royal Oak Underwriters, Inc.
